“What can a hospital, clinic, or doctor do?” This is what folks ask me when I bring up social determinants of health and the healthcare sector in the course of my work as a health analyst at Harris County Public Health’s (HCPH) Office of Policy and Planning in Houston. Similar to any local health department, the social determinants of health (SDH) are of central concern to my colleagues and me.
There are obvious barriers that cannot and should not be ignored when discussing SDHs, such as the lack of payment structures for health services. Resources are limited and organizations don’t always communicate with one another. Most providers receive minimal training on health behaviors, nutrition, and social issues. Even if a provider is aware of an environmental barrier, it may not be clear what to do about it. For example, how does a provider actually fix asthma when a child lives in an area with poor air quality?
Layered on top of these challenges, I live in Texas, a state with one of the highest uninsured rates, and a state that also chose not to expand Medicaid. To be honest, when I was tasked with assessing what our local healthcare partners were doing in response to SDHs, I was unsure if I would find much at all. Don’t get me wrong. Houston/Harris County has the largest medical center in the world. It is the fourth-largest city—and one of the most ethnically diverse cities—in the U.S., and it has a plethora of incredible organizations, research, innovations, and people doing their best to treat patients. Still, the city includes neighborhoods with glaring disparities.
So what can hospitals and providers do to address SDHs? After interviewing over 100 individuals representing hospital systems, clinics, physicians, health plans, medical schools, funders, academic institutions, and nonprofit organizations from within Houston/Harris County, Texas, and across the country, I can say: there’s plenty they can do.
Many in healthcare are exerting an incredible amount of energy to address SDHs, and our new “Moving Upstream” report provides examples from around the country. Activities include funding housing for patients, hosting farmers’ markets on hospital grounds, screening patients for SDHs and providing interventions, and partnering with legal aid societies to address housing violations reported by patients.
The process of creating the report itself has led to positive outcomes separate from the activities described in the report. More than a few times during the course of our interviews, an interviewee would discuss a project that was very similar to one happening at another institution we had interviewed. HCPH ended up taking on the role of a bridge organization between the different organizations, thus helping to break down silos. HCPH also grew stronger as a convener. Whether the projects were internally developed or drew from other partners’ works, the information and insights gathered have led to incredible collaboration on projects such as SDH clinical screening and the development of core SDH measures. Finally, because healthcare is a small community regardless of its size, our assessment became better known as we gathered information and insight, which created its own excitement and momentum for more SDH work.
Houston/Harris County is not utopia; far from it. We have the same issues as anyone else -- possibly more due to our size -- and there is more SDH work that needs to be done than is actually being done. However, we are blessed to have some incredible organizations and people trying their best to do the right thing while balancing the realities of business. We see the momentum building and the tide shifting in a positive direction. When you boil it down, healthcare’s response to SDHs in any locale will be determined by hard work, communication, beneficial information, sound planning, and sincerity. Sometimes it takes a singular entity and a singular effort to flip that first domino, but it is what we do together as a collective that helps build a healthy community for all Americans.
Executive Summary: Executive Summary - Moving Upstream: The State of Healthcare's Response
Full Report: Moving Upstream: The State of Healthcare in Houston/Harris County and Its Response to Social Determinants Report (2015-2016)
HCPH Website with resources on SDH: http://publichealth.harriscountytx.gov/Resources/Health-Data/Health-Equity